护理英语交班

护理英语交班NursingEnglishreportGeneralconditions•Goodmorning,everyone,•March21.2009Wearepassingnursingreportnow.•Therearetotal36patientsintheward,including3patientsdischarged,2admitted,2transferredin,2transferredout,1diedyesterday.各位,早晨好2009年3月21日护理交班病人总数:36出院病人数:3入院病人数:5转入病人数:2转出病人数:2死亡病人数:1•3patientswereperformedoperation.•ThenumberofDILcase:1•thenumberofpatientongradeonenursingcare:10手术病人数:3病危病人总数:1病重病人总数:2一级护理病人总数:10Dischargedcase•Bed3,WangHong,coronaryheartdisease（CHD）,anginapectoris,wasdischargedat9o’clockyesterdayaftertreatment.3床,王红,冠心病、心绞痛于9：00出院Deathcase•Bed29,ZhaoLiang,pulmonaryinfection,twotypeofrespiratoryfailure,multipleorganfailure,wasdied(passedon)at10:00yesterdayafterresuscitationfailure.29床,赵良,肺部感染,二型呼衰,多功能脏器衰竭,经抢救无效于10：00死亡Newadmission•Bed18,WeiHaiming,male,47yearsold,wasadmittedat10:00o’clockwithcomplainingofa15daysintermittentchestpainandpalpitation.•Thediagnosiswasuncertainchestpain,dysrhythmias,paroxysmalatrialfibrillation,bradycardia,hypertensionongrade3.18床魏海明胸痛原因待查,心律失常、阵发性房颤、窦性心动过缓、高血病3级患者，男性47岁，地方人员，于10：00入院。主因为发作性胸痛伴心慌15天，为进一步治疗入院。•Afteradmission,thedoctorLiXuehuawasnotifiedimmediatelyandtheadmissioninterviewwasdone.ECGatbedsideshowedsinusrhythm.BPwas130/88mmHg.Thelowsaltandlowfatdietwasserved.Dilatedcoronaryartery,anticoagulationandanti-hypertensiondrugsweretakenandgrade2nursingcarewasgivenasdoctor’sorders.入院后立即通知李学华医生,入院介绍已做.患者未诉胸痛、心慌，血压130/88mmHg.行床旁心电图示窦性心律.遵医嘱给予二级护理，低盐低脂普食，扩冠、抗凝、降压等药物治疗。•ThepatientsleptwellLastnightandbloodspecimenweretaken.Thevitalsignswerenormalinthemorning.病人睡眠好，晨起血标本已留，生命体征平稳.DILcase•Bed10，WangHua,coronaryHeartdisease,anginapectoris,acuteextensiveanteriormyocardialinfarction.Thepatientsuddenlycomplainedofchestpainat22:30•Oxygenwasgivenimmediatelyandtheflowratewas3L/min.ECGmonitoringwasstartedandshowedsinusrhythm.10床,王华，冠心病，心绞痛，急性广泛前壁心肌梗死.昨天22：30病人主诉心前区疼痛，立即给予吸氧3升/分，心电监护仪监护，心电示波示窦性心律，•Theheartratewas63beats/min.BPwas115/64mmHg.MeanwhileDr.ZhangXuewasinformed.•Aftertaking3tabletsofnitroglycerinsublinguallyat5minuteintervalsasindicated,thepainwaspersistent.TheECGshowedthe0.2-0.6mvofelevatedV1-V5Stsegment.Dr.ZhaoYongsawthepatient.心率63次/分，血压115/64mmHg,通知张学医生看病人，遵医嘱给予硝酸甘油mg舌下含服，症状无缓解，行床旁心电图检查示V1-V5ST段抬高0.2-0.6mv.二线赵勇副主任医师到场看病人。•Heparin100mginnormalsaline500mlandDopamine80mginnormalsaline500mlweregivebyIVinfusion.Thedropratewere500u/hand1.46ug/kg/minrespectively.ThepatientwasonDIL.遵医嘱给予静脉输入生理盐水500ml+肝素钠注射液100mg，滴速为500u/h,生理盐水250ml多巴胺注射液80mg，滴速1.46ug/kg/min，报病危。•Ivinfusionwerekeptpatent.Thepatientsleptintermittentlyintheevening.TheECGshowedsinusrhythm.Theheatratewasatrangeof63-74beats/minandBPwas91-115/53-64mmHg.Thepatientwasturnedevery2hoursandnowisonsupine(prone,lateral,Fowler’s,semi-Fowler’s)position.夜班输液通畅，患者间断睡眠，心电监护仪显示窦性心律，心率波动在63-74次/分，血压波动在91-115/53-64mmHg.每2小时翻身一次,现病人平卧位(伏卧位、侧位、半卧位、较低半卧位）。•Theskinwasintegrity.Thetotalinputwas400mlandtheoutputwas300ml.皮肤无破损，全天入量400ml，尿量300ml.Operationcase•Bed11,DuanRong,coloncancer.Aterbeingperformedthecolectomywithgeneralanesthesia,thepatientwasconsciouswhenhecametothewardat15:30.Thedressingkeptintegrityandtheouterdressinglayerhad’tbeenwetorsoiled.TheAbdominaldrainagetubewassecuredwellanddrained50mlbloodyexudates.11床,段荣,直肠癌,今日在全麻下直肠癌切除术,术后于15:30返回病房,清醒,血压154/96mmHg,切口敷料包扎好,外层敷料未见明显渗出.腹腔引流管固定通畅，引流液为血性。•Thenasogastrictubewasattachedtolowsuctionfordecompressionanddrained100mlofdark-greencolorofexudates.•Thecatheterizationwasmaintainedpatentanditsdrained1200mlofclearurine.持续胃肠减压通畅，引流墨绿色液体100ml.尿管通畅，尿色清亮，皮肤好。•Thecentralvenouscatheterwaskeptpatentandtherewerenorednessandswellingintheskin.Thesaturationofoxygenwascontinuouslymonitoredbypulseoximetryandthevalueswere95%to99%.•Thegrade1nursingcareandfastingfoodweregivenasdoctor’sorders.中心静脉输液通畅，穿刺部位无红、肿.持续血氧饱和度监测，SPO2维持在95-99%之间，术后遵医嘱给予一线护理，禁食.•Thepatientwaschangedthepositionevery2hoursandtheskinwasintegrity.ThepatientsleptintermittentlyLastnight.Thetotalintakewas2500mlandtheoutputwas1350ml.定时翻身，皮肤好。夜间间断入睡,全天入量2500ml,出量1350ml，其中尿量1200ml,腹腔引流50ml,胃肠引流液100ml.Preoperationcases•Ded3,SunYi,cholecystitis,cholelithiasis,willbeperformedthelaparoscopiccholecystectomywithgeneralanesthesia.•Theskinatandaroundtheoperativesitewasshaved.Preoperativepatienteducationwasdone.3床,孙义,胆囊炎,胆石症.患者常规准备于明日在全麻下行腹腔镜胆囊切除术.皮已备,术前指导已做,青霉素皮试(一).晚上给予清洁灌肠一次,大便3次，夜间睡眠好，晨起已禁食水。•Penicillinallergytestwasnegative.Thepatientwasgivenacleaningenema(laxative)andpassedwatery(loose)stool3times.•Hesleptwellatnightandtooknothingbymouth(NPO)inthemorning.Thevitalsignswerenormal.青霉素皮试(一).晚上给予清洁灌肠一次,解水样大便3次，夜间睡眠好，晨起已禁食水，生命体征平稳。Othernotes•Thepatientswhohadfever:•Bed8,SuHaokai,thetemperatureat14:00was39.0℃.Aftercoldcompressandtepid(coolwater)sponginggivingtothepatient,thebodytemperaturefellto37.8℃at14:30.发热患者:8床,苏浩凯,14点测体温为39.0℃,给予冰袋物理降温,温水擦浴.14:30体温降为37.8℃.Clinictestswillbedonetoday:•Bed15,WangYonglinisonnothing-by-mouthregimenforabdominalultrasound.•Bed32,XueHua,24-hoururinecollectionwasstartedtoday,thespecimenshouldbesentat8:00tomorrowmorning.今日拟检查15床王永林,今晨禁食水,行腹部B超检查.32床薛华,今日起留24小时尿,明天早8点标本送检.•That’sall•Nurseonduty:WangYan交班完毕.值班护士